Service Plan and Notice of Approval or Denial of HCBS Waiver Services

(A) Service Plan. (1) The MassHealth agency or its designee assigns a case manager to each participant under an HCBS waiver. (2) The participant will lead the service plan process where possible. The participant’s representative should have a participatory role, as needed and as defined by the participant, unless the legal representative has decision-making authority. (3) The service planning process must comply with requirements in the federally approved HCBS waiver application and HCBS waiver policies for service planning established by DDS or MRC, and must include identification of the strengths, preferences, and cultural considerations of the participant, goals, desired outcomes, clinical and support needs, HCBS services and supports to be furnished, strategies for solving disagreement within the process, and modifications that are supported by a specific assessed need and justified in the service plan. (4) The service plan must also comply with all requirements in the federally approved HCBS waiver application and HCBS waiver policies for service plans established by DDS or MRC, including but not limited to, containing the HCBS services and supports to be furnished, the amount, frequency, and duration of each service, and the type of provider to furnish each service; reflecting that the setting in which the participant resides was chosen by the participant; reflecting clinical and support needs as identified through an assessment of functional needs; reflecting risk factors and measures in place to minimize them; and documenting that any additional conditions are supported by a specific assessed need and justified in the service plan. (5) The service plan may not be backdated. (B) Notice of Approval. For all HCBS waiver services authorized and included in a service plan, the MassHealth agency or its designee will provide a copy of the service plan to the participant. The service plan must contain, at a minimum, the types of HCBS waiver services to be furnished, the amount, frequency, and duration of each service, and the effective date of the authorization. (C) Notice of Denial or Modification and Right of Appeal. (1) A participant and the participant’s authorized representative, as applicable, will receive a written notification from the MassHealth agency or its designee whenever a service plan contains a denial or modification of a requested HCBS waiver service requested by a participant or the participant’s authorized representative. The notification will describe the reason for the denial or modification and provide information about the participant’s right to appeal and the appeal procedure. (2) A participant may request a fair hearing whenever the MassHealth agency or its designee denies or modifies the participant’s request for an HCBS waiver service. As described in 130 CMR 630.409, a denial or modification includes the MassHealth agency’s denial, suspension, reduction, or termination of a requested HCBS waiver service as well as the agency’s failure to act on the participant’s request for an HCBS waiver service within 30 days of receiving such request. The participant must request a fair hearing in writing within the time limits set forth in 130 CMR 610.015(B)(1) or (2), as applicable. The Office of Medicaid Board of Hearings conducts the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (D) Information for HCBS Waiver Providers. The MassHealth agency or its designee will furnish applicable information from each service plan to an HCBS waiver provider that provides an HCBS waiver service to a participant. Applicable information will include the amount, frequency, duration, and effective date of the HCBS waiver service that is authorized in the service plan. The information will be provided in a manner and format specified by the MassHealth agency or its designee. (E) Information for Fiscal Intermediary (FI). Waiver participants will be given the option to self- direct certain waiver services as specified in the particular HCBS waiver in which they are enrolled. Participants who choose to self-direct will have those self-directed waiver services listed in their service plan. Information regarding the frequency and duration of the self-directed services in the service plan must be forwarded to the FI. The information will be provided in a manner and format specified by the MassHealth agency or its designee.